A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal cannula at 4 liters per minute. Which assessment finding indicates a need for immediate action?- Nurselytic

Question 1 of 5

A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal cannula at 4 liters per minute. Which assessment finding indicates a need for immediate action?

A. The client's respiratory rate is 14 breaths per minute. B. The client's oxygen saturation is 92%. C. The client reports shortness of breath. D. The client's respiratory rate is 24 breaths per minute.

Correct Answer: C

Rationale: A report of shortness of breath (C) indicates that the client is not tolerating the oxygen therapy well and may need an adjustment. Shortness of breath is a critical symptom in a client with COPD, as it signifies potential respiratory distress. A respiratory rate of 14 (A), oxygen saturation of 92% (B), and respiratory rate of 24 (D) are not as immediately concerning as they may still fall within acceptable ranges for a client with COPD.

Question 2 of 5

During the digital removal of a fecal impaction, the nurse should stop the procedure and take corrective action if which client reaction is noted?

A. Temperature increases from 98.8° to 99.0° F. B. Pulse rate decreases from 78 to 52 beats/min. C. Respiratory rate increases from 16 to 24 breaths/min. D. Blood pressure increases from 110/84 to 118/88 mmHg.

Correct Answer: B

Rationale: During digital removal of a fecal impaction, a vagal response can occur due to stimulation of the anal sphincter. If the client experiences bradycardia (pulse rate decreases), the nurse should stop the procedure immediately and take corrective action to prevent any complications.

Question 3 of 5

A female client with chronic back pain has been taking muscle relaxants and analgesics to manage the discomfort, but is now experiencing an acute episode of pain that is not relieved by this medication regimen. The client tells the nurse that she does not want to have back surgery for a herniated intervertebral disk, and reports that she has found acupuncture effective in resolving past acute episodes. Which response is best for the nurse to provide?

A. Surgery removes the disk and is the only treatment that can totally resolve the pain B. The medication regimen you previously used should be re-evaluated for dose adjustment C. Massage and hot pack treatments are less invasive and can provide temporary relief D. Acupuncture is a complementary therapy that is often effective for management of pain

Correct Answer: D

Rationale: Acknowledging the effectiveness of acupuncture is important, as the client has reported its success in managing her pain previously.

Question 4 of 5

During the admission assessment of a terminally ill male client, he states that he is an agnostic. What is the best nursing action in response to this statement?

A. Provide information about the hours and location of the chapel B. Document the statement in the client's spiritual assessment C. Invite the client to a healing service for people of all religions D. Offer to contact a spiritual advisor of the client's choice

Correct Answer: B

Rationale: Documenting the client's statement in the spiritual assessment is the best nursing action in response to his disclosure of being an agnostic. This respects the client's beliefs and preferences, ensuring that care is tailored to his individual needs. It also demonstrates a commitment to providing holistic and patient-centered care.

Question 5 of 5

A healthcare professional stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later, the client has to have the leg amputated and sues the healthcare professional for malpractice. What is the most likely outcome of this lawsuit?

A. The Patient's Bill of Rights protects clients from malicious intents, so the healthcare professional could lose the case. B. The lawsuit may be settled out of court, but the healthcare professional's license is likely to be revoked. C. There will be no judgment against the healthcare professional, whose actions were protected under the Good Samaritan Act. D. The client will win because the four elements of negligence (duty, breach, causation, and damages) can be proved.

Correct Answer: C

Rationale: The Good Samaritan Act protects healthcare professionals who provide care in good faith and offer reasonable assistance in emergencies. This law shields them from malpractice claims, even if the outcome for the client is unfavorable. Therefore, in this scenario, the healthcare professional is likely to be protected from judgment under the Good Samaritan Act.

Nurselytic

HESI RN

HESI RN

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